Someone with acute hepatitis is is likely to present with which clinical features:

How is rabies diagnosed?

1. Virus/viral antigen can be indentified in infected tissue and can be isolated to saliva as well
2. Four-fold increase in serum AB titers
3. Indentification of Negri bodies histologically
4. PCR detection of virus RNA

Which viral infection that can replicate in the dermis and epidermis, travel to the DRG via sensory nerves and reside as a latent infection, is associated with Bell's Palsy?

Treatment of ACUTE UNCOMPLICATED CYSTITIS

-empiric treatment with oral BACTRUM (TMP/SMX) for 3 days
-use of a CIPROFLOXACIN (FLUOROQUINOLONE) for 3 days is appropriate if resistance rate is high in community to BACTRUM
-amoxacillin not used as much due to high resistance

Which three areas of the united states are most commonly affected by lyme disease?

How is necrotizing fasciitis treated?

A patient presents with lethargy, malaise for a period of 3 days to 2 weeks with other symptoms including: fever, sweats, headaches, arthralgias, diarrhea, sore throat, LAD, and a truncal maculopapular rash. The patient states that the majority of his symptoms have lessened to a minimum, and wants to know if his possible blood transfusion after he was diagnosed with SCA may have been what spawned it?

This is a typical presentation of someone with PRIMARY INFECTION of HIV. Currently, the patient had 3days-2 weeks of flu-like/mono-like symptoms. HIV has an incubation period of 2-4 weeks after its initial infection before its viral load is high enough to have an effect.

It is important BUT difficult to catch patients with primary HIV because of the benefits of early antiretrovirl therapy.

Treatment of chronic HBV:

1. AIDS: those with AIDS are at risk for toxo when count < 400
2. immunosuppression (chemo)
3. Travel in underdeveloped countries
4. Exposure to mosquitos (vectors) from endemic areas
5. Exposure to wild animals (BATS) in an endemic area for rabies

CLINICAL features of acute bacterial arthritis (SEPTIC arthritis)

Diagnosis of infectious mononucleosis is made by:

1. Serology
-Monospot test for detection of heterophile AB
-Heterophile antibodies are positive within 4 weeks of infection with EBV mononucleosis and are undetectable by 6 months. Thus a positive monospot test indicates acute infection with EBV mononucleosis.
-Heterophile antibodies are negative and do not form in CMV mononucleosis
EBV specific antibody testing is performed in cases inw hich diagnosis is not straightforward and dont by ELISA.

In nursing home residents, the most common nosocomial pathogen with predilectation to the upper lobes?

DIAGNOSIS of pyelonephritis:

1. UA: pyuria, bacteriuria, WBC casts
2. Urine culture: get from all patients with pyelo
3. Blood culture: get from all ill appearing pts and hospitalized patients
4. CBC: left shift with leukocytosis
5. RFT: should be preserved; impairment can be reversible
6. Imaging studies: if Rx fails or if pt with complicated pyelo. Get renal US, then CT, IVP, or retrograde ureterogram.

What is Erysipelas? How does this differ from an uncomplicated cellulitis?

Erysipelas is a cellulitis that is usually confined to the dermis and lymphatics. This is caused by GAS with a presentation of well-demarcated, RED, PAINFUL lesion on the lower extremities and the face.

Unlike that of cellulitis, erysipelas often has predisposing factors of lympatic obstruction (pst radical mastectomy) local trauma or ascess, fungal infections, DM or alcoholism.

CHRONIC HEPATITIS is more likely to occur in acute hepatitis 1-10% of patients with Hepatitis __ virus versus patients diagnosed with Hepatitis __ virus whose chance is between 80-90%.

Oval budding yeasts known for their formation of hyphae and long pseudohyphae.

Toxic-shock syndrome (TSS) is most commonly associated with?

Menstruating women and tampon use but can occur in both male and females secndary to surgical wounds, burnes, infected insect bites. This is due to an enterotoxin by S. Aureus or less frquently an exotoxin of GAS.

What are the clinical findings of patients with C. Trachomatis L1-L3 (lymphogranuloma venereum)?

PAINLESS ulcer at site of inoculation that can often go unnoticed. A few weeks post infection, it will have spread to inguinal lymph node and developed unilateral tenderness and can result in more severe issues that can resemble that of ulcerative colitis and/or orther IBDs. For example, PROCTOCOLITIS may develop with perianal fissures and rectal stricture resulting in the obstruction of lymphatics and elephantitis of the genitals.

Pathophysiology of HIV:

a. Most common virus assciated iwth HIV is the HIV type 1 human retrovirus
b. Attaches to surface of CD4+ T cells (target of HIV-1)-enters cell by binding to GP120 and entering GP40 the cell-uncoating-transcribing RNA into DNA using host machinery and OWN reverse transcriptase.
c. Particles are produced each day by activated CD4 cells. When the virus enters into the lytic phast of infection, the CD4+ cells are destroyed and its depletion of the bodys arsenal of CD4 cells weakens the cellular immunity of the host.

How should one approach a patient with recurrent UTI infections?

If relapse occurs within 2 weeks of cessation of treatment, continue treatment fr 2 more weeks then get a urine culture

OR

Treatment for uncomplicated cystitis - if patient has more than two UTIs per year:
1. Give chemoprophylaxis (one dose of TMP/SMX after intercourse or at the first signs of symptoms)
2. Alternative lowdose prophylactic AB for 6 mo (TMP/SMX)

Atypical pneumonia syndrome is associated with which pathogens?

CAP can be either typical (S. Pneumo) or atypical in presentation. Those which are commonly associated with atypical include: Mycoplasma pneumonia, Chlyamydia pneumonia, Legionella, Coxiella Burnetti (Q Fever), and chlyamydia psittachi. Viruses are included in the atypical presentation

Complications for pneumonia

# 1 = pleural effusion ("parapneumonic effusion"
1. Seen in > 50% patients with CAP on routine CXR
2. Most uncomplicated courses and resolve with treatment of the pneumoia with AB however if it is complicated with an empyema - thoracentensis should be performed if LL decubitius film shows >1cm fluid. Get grain stain, culture, pH and cell count. Then determine amt of glucose, protein and LDH to differentiate between an exudative versus nonexudative

What is "cellulitis" and what are the two most common causes?

What is the treatment of RABIES postexposure?

1. CLEAN WOUND!
2. If wildlife bite (bat/raccoon) - capture animal if possible, destroy it, send to lab for immunofluorescence of brain tissue
3. If bitten by healthy dog/cat in endemic area, capture animal and observe for 10 days. If not change in animal condition then rabies is not present.
4. IF KNOWN rabies exposure then perform both of below:
-Passive immunization: admin human rabies Ig to patients into wound and into the gluteal region
-Administer the antirabies vaccine in 3 doses IM via the deltoid or thigh over a period of 28 days.

Unlike that of C. Trachomatis, how does N. Gonorrhea present in males versus females?

How is Herpes Simplex transmitted?

Contact with people who have the ACTIVE ULCERATIONS OR SHEDDING OF VIRUS from the mucous membrane. HSV-1 is usually nonsexually transmitted whereas HSV-2 is sexually transmitted nearly 100% of the time.

If a patient has a history of <3 doses, unknown status or > 10 YR sincle last "booster" of tetanus, what should be done for wound management in clean/minor wounds? Other wounds?

Diagnosis of HIV requires which tests?

Two are required:
1. ELISA - screening test for detecting antibody to HIV; becomes positive 1-12 weeks after infection. These tests are 99% sensitive (and thus a negative ELISA excludes HIV as long as the patient hasnt had prior exposure before testing - hence seroconversion). A positive ELISA wins the patient another test...

2. Western blot - performed after a positive ELISA for confirmation. This is a highly specific test >99% thus will rule out if negative.

Most common bacteria associated with osteomyelitis?

Cryptococcus neoformans is a budding, round yeast with a thick _ capsule. Cryptococcus is most commonly associated with ____ droppings and seen in patients with advanced HIV. Infection is often secondary to inhalation of fungus into lungs - hematogenous spread may involve the brain and meninges.

What are the CLASSIC findings of the flu? What are the two major types?

Antigenic type A and B which have many segments (H and N) and can thus undergo genetic drift and shift which is what causes both epidemic and pandemics. Annual epidemics are due to minor genetic changes of reassortment and are NOT life threatening. OH **** genetic drift incur with PANDEMICS and are secondary to genetic recombination and are fatal to even healthy hosts.

How are chancroids transmitted and how do we diagnose it separate from HSV2?

Transmission by sexual contact with an incubation period of 2-10 days.

Diagnosis: PAINFUL genital ulcers that will never go systemic and will never disseminate. Tender LAD, ruled OUT syphilis via a negative VRDL and FTS-ABS and darkfield microscopy. HSV ruled out based on clinical presentation or negative culture for HSV (Tzank) negative.

How is chlamydia diagnosed? How long does it take post copulation for symptoms to present?

What should you expect to find in CSF that has been tested in suspician of an aseptic cause?

1. Nonpyogenic inflammatory response in CSF therefore there should be an increase in monoculear cells and a lymmphocytic pleocytosis present.
Protein: WNL or slightly elevated
Glucose: WNL
CSF: may be completely normal

How is cellulitis and its agent diagnosed?

Approach to diagnosing CAP

Step 1: Diffferentiate lower RTI versus other causes of cough and from upper RTI
Step 2: if nasal discharge, sore throat, ear pain predominates, upper RTI is likely
Step 3: once lower tract infection is suspected, the next task is to differentiate between penumonia and acute bronchitis. Clinical features including cough, sputum fever and SOB are not reliable in differentiating betwen lower RTI and bronchitis
Step 4: CXR is the ONLY reasonable method of differentiating between pneumonia and acute bronchitis

Course of hepatitis C post subclinical infection?

Q fever is secondary to infection of _____ ____ which is a gram _____ organism in the family of ______. Transmission is by ____ and not tick, its reservoir is in farm animals, and clinically there is a fever but no rash. Acutely, will have constitutional symptoms; Chronically will have endocarditis.

How is botulism diagnosed?

Can the annual "flu" be treated with AB?

No, treatement for VIRUSES do not include AB which is for BACTERIA. Treatment is largely supportive with some antivirals capable for use if given within the first 24 hours of illness.
Amantadine
Rimantadine

Both decrease the duration of symptoms. AB are ONLY INDICATED if secondary bacterial infections occur (number one cause of death in the elderly from influenza virus is the secondary bacterial infection) - this is why vaccinations are critical.

CANDIDIASIS is the most common cause of esophageal dysphagia in patients with HIV once CD4 counts have reached:

What should be ordered to diagnose pneumonia?

PA and later CXR required to confirm the diagnosis
1. Considered sensitive - if CXR no suggestive of penumonia, do not treate the patient with AB. After treatment changes evident in CXR usually lag behind the clinical response for 6 weeks maximum.

How long does Herpes labialis (cold sores) most commonly last for?

How does tertiary syphilis differ from primary, secondary, and latent?

33% of untreated syphilis patients in the latent phase enter this phase (tertiary)
-occurs after the development of primary infection - up to 40 years later
-Manifestations include: CV syphilis (vasovasorum of aorta), or neurosyphilis, or subcutaneous granulomas called "gummas"

Primary TB v. Secondary TB

Primary: Bacilli are inhaled and depositied into lung and ingested by alveolar macrophages. THose that survive disseminate by lymph and blood. Granulomas form and wall off the MB to immune defense. This occurs in O2 rich areas like the lungs and are therefore aerobes. After resolution of primary infection, the organism remains dormant within granuloma.

Secondary: Occurs when the hosts immunity is weakened (HIV, immunosuppressants like anti-TNF AB, chemotherapy, substance abuse and poor nutrition. Manifests in the most oxygenated aspect of the lungs (apical/posterior segments).

Acute bacterial arthritis can be caused by:

1. S. Aureus is the most common in adults and children
2. An important gram-negative agent in N. Gonorrhea that is common in YOUNG, SEXUALLY ACTIVE ADULTS
3. Pseudomonas or Salmonella if history of sickle cell disease, immunodeficiency, or IV drug abuse.

What does the Hepatits B surface antigen represent (HbsAg)?

Present in acute or chronic infection that can be detected within 1-2 weeks of infection. Persists through chronic hepatitis regardless of whether symptoms are present - if virus is cleared then HbsAg is NOT detectable.

How can primary TB (latent) be differentiated from secondary TB (active)?

What is lymphadenitis?

Inflammation of a lymph node (1 or >) caused by local skin or soft tissue bacterial infections (GAS/Staph). Likely, will have fever, tender LAD or regional lymph nodes, red streadking of skin from wound or area of cellulitis.

Complications include: thrombodid of adjacent veins sepsis, and even death if untreated.

How is the VIRAL LOAD determined in patients with HBV?

TREATMENT for MALARIA

1. Use chloraquine phosphate unless resistance suspected
2. Use quinine sulfate and tertracycline or atovaquone-proguanil and mefloquine if RESISTANT to chloroquine
3. Use chloraquine and IV quinidine and doxycyline for P. Falciparum
4. Use chloraquine and PRIMAQUINE in patients with P vivax or P ovale due to latency/dormancy found in hepatocytes due to dormant hypnozoites. Must add a 2 week regimen to it.

What is the prophylaxis for people wanting to travel to areas endemic for MALARIA?

Rx of Bacterial Meningitis?

EMPIRIC THERAPY
1. IV AB immediately after specimans taken via the LP. DO NOT DELAY even in case of CT scan. If cloudy, begin immediately according to the patients age and modify treatment as appropriate based on the gram stain, culture and sensitivity findings.
3. Steroids - if cerebral edema is present
4. Vaccination - all adults > 65YO for S. Pneumococcus
5. Vaccination - all adults with aslpenia for S. pneumo, N. Meningitidis, H. Influ
6. Prophylaxis - RIFAMPIN or CEFTRIAXONE for all close contacts with NM,
-1 dose of IM ceftriaxone

How to dx osteomyelitis:

1. WBC count
2. ESR and CRP: nonspecific but are markers of inflammation that will b elevated in the appropriate clinical setting. GOOD FOR TRACKING RESPONSE TO THERAPY
3. NEEDLE aspiration of infected bone or bone ciopsy obtained in the OR is the most direct and accurate means of diagnosis.
4. Plain radiography (no soooo good because takes 10 days to show
5. Radionucleotide bone scan (OK to use 2-3 days post infection but is nonspecific)
6. MRI IS THE MOST EFFECTIVE IMAGING STUDY FOR DIAGNOSING OSTEOMYELITIS AND ASSESSING THE EXTENT OF DISEASE PROCESS - take time for results is issue

Disseminated or invasive disease of candida is common in patients who are immunosuppressed. What manifestations can result from systemic candida?

What percent of patients with secondary syphilis will continue to latent syphilis rather than teriary syphilis?

30% go to latent phase if left untreated in secondary. This includes (+) serologic tests resulting in the ABSENSE of clinical symptoms or signs. 66% of pateints remain asymptomatic whereas 33% continue to tertiary syphilis

Aseptic causes occurs secondary to nonbacterial pathogens (virus, parasites and fungus), Often difficult to distinguish from acute so if ANY uncertainty, treat for acter bacterial menigitis. Much better prognosis than acute bacterial

If a 17 YO sexually active female presents to the clinic with symptoms including urethral discharge that is purulent, intermenstral and postcoidal bleeding and dysuria with pharyngitis and conjunctivitis, what should your differential dx include?

N. Gonorrhea (infection of pharynx, conjunctiva, and rectum can occur)

AB therapy:
1. Outpatients <60YO: S pneumonia, mycoplasma, chylamidia, legionella = Macrolides (azithro, erythro, clarithromycin), doxycycline are all first line. Second line try fluoroquinolones (cipro, moxifloxacin). Do not use 3rd generation ceph or penicillins because not good coverage for atypicals.
2. Outpatents >60YO: more likely to have typicals (S pneumo, H influ, Klebsiella) so 2nd or 3rd generation cephalosportin is the first line treatment. Alternatives include that of zosyn (amoxicillin/clavulanic acid, macrolides, and fluoroquinolones (levo and moxifloxacin - these are two with good pneumonoccal coverage too).

Leptospirosis is transmitted by contaminated ______ and have reservoirs in _____. Clinical findings are anicteric (rash, LAN, inc LFTs) or icteric (renal and or liver failure with vasculitis, vascular collapse.

Diagnosis by:
Treatment:

Extrapulmonary TB versus Miliary TB

Extrapulmonary TB: indivudals with impaired imunity may not be bale to contain bacteria at primary or secondary stage of infection ang therefore the disease will spread to other locations throughout the body (Pott's disease - vertebral body)

Hospitalized patients should receive which two AB for coverage of pneumonia causing agents?

A patient was recently treated with acute uncomplicated cystitis using a 3 day course of BACTRUM (TMP/SMX) and reports no change in pain and urination and also reports new onset of fever. What is your next step?

Treat presumptively for pyelonephritis if the condition fails to respond to a short course of AB for what was thought to be an acute uncomplicated cystitis.

Chronic hepatitis patients can be asymptomatic for years and may present with late comlications of hepatitis such as either ______ or _________

Ehrlichiosis is an intracellular gram negative bacteria that is transmitted by ___ in the family of ____ and has reservoir in ____. Fever, chills, malaise, rash, renal failure and GI bleeding can occur.

Diagnosis:
Treatment:

HEADACHE, Malaise, myalgia that occurs in conjunction with a worsening illness over hours to days. Patients have signs of meningitis in addition to altered sensorium including confusion, delirium, disorientation and behavior abnormalities. Focal neurologic findings may include that of hemiparesis, aphasia, CN lesions and seizures.

NEUROTOXINs produced by spores of ______ _________ that is a GRAM POSITIVE ANAEROBIC BACILLUS. This proliferates and produced an exotoxin in contaminated wounds and can thus inhibit transmitters at the NMJ

ABPG (allergic bronchopulmonary aspergillosis) occurs in patients who a type ___ hypersentitivity reaction to inhaled spores of aspergillus. This will present with both _____ and _____ and recurrency of such exacerbations are common

CXR in a typcial presentation of CAP versus an atypical presentation of CAP

Treatment of Fever of UNKNOWN origin

1. AB and coticosteroids may mask patterns of fever response. Empiric AB should be based on severity of illness.
2. If patient not actuely ill, observation along
3. If FUO, some patients resolve spontaneoulsy without every being dx

Mortality of patients with HIV is due to:

Treatment of OM:

Give IV AB for extended periods of time 4-6 weeks. Initiate AB therapy only after microbial etrioloy is narrowed based on data from cultures.

1. Empiric therapy requires penicilinase-R penicillin (oxacilin) OR a first generation cephalosporin (CEFAZOLIN)
2. Addition of an aminoglycoside or a b-lactam AB if pssibility of GRAM-NEG
3 Surgical debridement of infected necrotic bone is important

How does disseminated HSV differ from HSV1 and HSV2?

Viral load of HIV-1 RNA levels facilitate the anti-viral treatment in which way?

1. Assess response to and adequacy of antiretroviral therapy, provides complementary prognostic information to the CD4 count.
2. If viral load is >50 after 4 mo treatment, modification to regimen may be necessary.
3. Measured at TIME of diagnosis and every 3-4 months thereafter. (both viral load and CD4)